SOS (Save Our Students) Bully Tip Form
This form is used to submit tips on harassment, intimidation and bullying. Bullying is when a person or group of people repeatedly cause hurt or harm to a person or group of people who feel helpless to respond.
Role of person completing form
Pin Oak Student
Pin Oak Parents
Targeted Student's Name (victim)
How did you learn about the bullying
Did a physical injury result from the incident
Describe any physical injuries if they occurred.
Why do you think the harassment, intimidation or bullying occurred?
Name of school adult you've already contacted (if any)
Name of Bully or Bullies
Hitting, kicking, shoving, spitting, hair pulling or throwing something at the student
Getting another person to hit or harm the student
Teasing, name calling, making critical remarks or threatening in person, by phone, by e-mail, etc
Putting the student down and making the student a target of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Making the student fearful, demanding money or exploiting
Spreading harmful rumors or gossip
Cyber bullying (bullying by calling, texting, emailing, web posting, etc)
Where did the incident happen?
During a School Activity
Off school property
Name of reporting person (unless wish to remain anonymous)
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This form was created inside of Henderson County Board of Education.